Clinical Question

Do intra-articular corticosteroids improve pain and function and decrease cartilage loss in adults with osteo-arthritis of the knee?

Bottom Line

This well-done study found that regular three-month intra-articular injections of triamcinolone for two years resulted in no significant difference in pain and function assessments compared with saline. However, a significant increase in cartilage loss and damage did occur in patients receiving corticosteroids compared with saline. This study confirms the findings of the only other published study with a low risk of bias (see Synopsis). (Level of Evidence = 1b)

Synopsis

Although intra-articular corticosteroids are commonly used for the treatment of knee osteoarthritis, data are limited in terms of benefits and safety. The most recent Cochrane review on this topic evaluated 27 randomized controlled trials (26 with a high risk of bias) and found minimal improvement in pain and function in the short-term with corticosteroids compared with placebo. The only study with low risk of bias found no benefit from corticosteroids (Jüni P, et al. Cochrane Database Syst Rev. 2015;(10):CD005328). These investigators recruited 140 adults, 45 years or older, with knee osteoarthritis diagnosed using standard national criteria. Eligible patients randomly received (concealed allocation assignment) either ultrasound-guided intra-articular triamcinolone (40 mg) or saline injections every three months for two years. Patients, clinicians administering the injections, and outcome assessors remained masked to treatment group assignment. Pain and function assessments based on validated questionnaires and physical examination occurred regularly throughout the study. Periodic magnetic resonance imaging occurred at 0, 12, and 24 months to evaluate changes in knee cartilage volume over the two-year period. Complete follow-up occurred for 95% of patients at two years.

Using intention-to-treat analysis, pain and function scores did not significantly differ between the two groups. However, the rate of cartilage loss and damage was significantly greater in the triamcinolone treatment group. There were no significant group differences in serious adverse events.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (any)

Reference: McAlindonTELaValleyMPHarveyWFet alEffect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA2017;317(19):1967–1975.